Changes in Healthcare in the United States for Persons Living with HIV

Changes in Healthcare in the United States for Persons Living with HIV

The ACA also mandates that dependents up to the age of 26 may be included on parents’ insurance plans. Before the law, dependent children often lost this option for coverage when they turned 19, or 22 if they were full-time students. Given that over 17% of new HIV diagnoses occur among individuals aged 19-25, this is a potentially important new source of coverage for this group.¹²⁹

As of 2014, uninsured PLWH and other individuals whose incomes are too high to qualify for Medicaid may seek coverage through state health insurance exchanges with subsidies provided on a sliding scale to households earning 100-400% of the federal poverty level. Insurance plans on these exchanges must conform to specific regulations. Among the important new regulations is a ban on insurance companies refusing to provide coverage due to pre-existing conditions, such as HIV infection. Insurance plans on the exchanges may also not impose annual or lifetime caps on coverage, which is important for PLWH whose average lifetime costs of care may exceed $400,000 when diagnosed late in the course of disease.¹³⁰ Finally, insurance plans must include coverage for certain essential benefits. These include inpatient, outpatient and emergency healthcare services; mental health and substance abuse treatment, including behavioral counseling services; laboratory services; and prescription drug coverage. Coverage of expensive ART regimens by insurers on health exchanges may help relieve some of the burden on overstretched ADAPs. Among PLWH, rates of mental illness and substance abuse are high, making coverage for services to treat these disorders especially important.¹³¹ Treatment for these disorders may also improve adherence to ART and slow the clinical progression of HIV.^132-134

Implementation of the ACA will also have important implications for the diagnosis of new HIV infections. Presently, it is estimated that about 20% of PLWH in the United States are not aware of their diagnosis and this group is responsible for about half of HIV transmission.¹³⁵ For multiple reasons, expanding insurance coverage is likely to result in increased screening for HIV among all Americans. First, insurance lowers the cost of HIV testing to individual patients. Second, insurance increases opportunities for testing by engaging individuals with the healthcare system. Third, insurance provides resources to facilitate treatment of the disease, if detected, thereby making screening more valuable than it would otherwise be if treatment were unavailable. Because of these factors, it is estimated that Medicaid expansion alone will result in the screening of 450,000-600,000 additional individuals and the diagnosis of 2,500-3,300 additional HIV infections by 2017.¹³⁶ Increases in routine HIV testing will enable earlier initiation of treatment that prolongs survival and reduces disease transmission.^130,137-139

Costs of Healthcare among Persons Living with HIV

The expansion of publicly funded insurance programs and subsequent increased engagement of PLWH in treatment and care is not expected to come cheaply. In 1995, the federal government allocated $3.7 billion to HIV care, in 2004 this number had nearly tripled to $11.0 billion, and in 2015 the government is expected to spend $17.5 billion on health care services and treatment for PLWH in the United States.^140,141 By improving survival, early diagnosis and treatment of HIV infection actually increases lifetime costs of care for PLWH.¹³⁰ Medications, laboratory services, outpatient healthcare utilization, and inpatient healthcare utilization each contribute to healthcare costs. Understanding the sources of healthcare spending and the factors that influence healthcare utilization among PLWH is important to policy-makers and third-party payors who are tasked with allocating a limited pool of healthcare resources.
Medications are, by far, the largest component of healthcare costs among PLWH. Even accounting for discounted pricing negotiated between ADAPs and pharmaceutical companies, typical ART regimens can cost $14,000-$30,000 per patient, per year.^130,142,143 On average, non-HIV-related medications contribute an additional $2,400 per year. When a patient’s CD4 count is low, medications for prophylaxis against opportunistic infections add another $1,000 per year. Among PLWH with well-controlled disease, medications are the source of 66-78% of healthcare spending. As CD4 counts decline, medication costs tend to rise slightly, but the increase in medication costs is outpaced by other sources of healthcare spending, such as inpatient healthcare utilization. It is only when CD4 count dips below 50 cells/mm³ that medications no longer represent the majority of healthcare costs.^142,143 Medications are estimated to cost $351,000 over the lifetime of care for someone diagnosed late in his or her disease course and $581,000 for someone diagnosed early.¹³⁰ As life expectancies for PLWH continue to rise, the costs of lifelong ART can also be expected to rise. When patents on the earliest generations of antiretroviral drugs expire, cheaper generic versions of these drugs will become available in the United States. Healthcare providers and policy-makers will face difficult decisions regarding how to balance the cost-savings of generic medications with the often better tolerability, efficacy, and ease-of-use associated with newer, brand-name medications.¹⁴⁴

Laboratory costs represent the smallest component of healthcare costs among PLWH. Baseline tests include HIV drug resistance genotyping and screening for various antibodies and comorbidities. Also, HIV RNA, CD4 count, blood counts, kidney and liver function testing are performed at baseline and then again at regular intervals.^64,65 As PLWH live longer, the number of tests performed over their lifetimes may increase, but the costs of these tests are also declining substantially as laboratory technology improves. In 1997, an HIV RNA test cost between $125 and $198.¹⁴⁵ In 2008, the test cost $90.¹⁴² Guidelines are also moving toward less frequent laboratory monitoring among PLWH with well-controlled disease.^64,65 Presently, laboratory costs account for less than 5% of healthcare spending among PLWH.^142,143

Despite routine outpatient primary HIV care visits typically scheduled every 3-6 months even for persons with well-controlled HIV, outpatient care represents a relatively small portion of healthcare costs. According to the Medicare National Physician Fee Schedule for 2014, the national facility unit cost for an outpatient visit billing for the most complex level of patient evaluation and management (CPT code 99215) was only $111.41.¹⁴⁶ Outpatient visits contribute only 2-10% toward the overall costs of care among PLWH, varying slightly according to CD4 count.^142,143

Hospitalization is a particularly costly form of healthcare utilization and is potentially modifiable, therefore warranting special attention. Among persons with a CD4 count above 500 cells/mm³, hospitalizations account for just 10-14% of healthcare costs. Among persons with a CD4 count below 50 cells/mm³, they account for 49-60% of costs.^142,143 This underscores the importance of hospitalization as a marker of disease severity. It also highlights the importance of early initiation of ART in order to prevent CD4 decline, halt disease progression, and reduce inpatient utilization. Interventions such as influenza vaccination and pneumococcal vaccination have been shown to reduce hospitalization rates and healthcare costs in specific populations and are now recommended for all PLWH in the United States.^64,147-149 Identifying additional interventions to reduce hospitalizations among PLWH should be a research priority and requires understanding of the factors that contribute to hospitalization risk in this population.

Directory: bitstream -> handle -> 1774.2
handle -> Master of science
handle -> The Economics of Technology Sharing: Open Source and Beyond Josh Lerner and Jean Tirole
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handle -> Mobile augmented reality applications for library services
handle -> Libraries, Archives, and Museums as Epistemic Infrastructure1

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